Nursing Elites

1. When caring for a child with hyponatremia, a nurse delegates care to a licensed vocational nurse (LVN) and instructs the LVN to promptly report which clinical manifestation?

• A. Seizures
• B. Respiratory distress
• C. Hyperthermia
• D. Bradycardia

Correct answer: A

Rationale: Seizures are a significant concern in severe hyponatremia as they indicate potential neurological complications and the need for urgent intervention to prevent further harm to the child. Prompt reporting of seizures allows for timely assessment and appropriate treatment to ensure the child's safety and well-being.

2. A healthcare provider is assessing an infant who has hydrocephalus and is 6 hours postoperative following placement of a ventriculoperitoneal shunt. Which of the following findings should the provider report to the healthcare provider?

• A. Decreased urine output
• B. Temperature of 37.5 degrees C (99.5 degrees F)
• C. Heart rate 130/min
• D. Leakage of cerebrospinal fluid

Correct answer: D

Rationale: The provider should report the leakage of cerebrospinal fluid to the healthcare provider as it may indicate shunt malfunction or infection, requiring immediate attention to prevent complications. Decreased urine output, a temperature of 37.5 degrees C, and a heart rate of 130/min are common postoperative findings and may not be directly related to shunt function. While these findings should still be monitored, they do not require immediate reporting like cerebrospinal fluid leakage.

3. A nurse is caring for a child who has a new diagnosis of osteomyelitis. Which of the following actions should the nurse take?

• A. Administer aspirin for pain.
• B. Apply ice to the affected area.
• C. Monitor the child’s weight daily.
• D. Limit the child's activity.

Correct answer: C

Rationale: The nurse should monitor the child’s weight daily to assess the effectiveness of treatment for osteomyelitis and detect potential complications.

4. The nurse is preparing to administer a daily dose of digoxin. What is the priority nursing intervention?

• A. Analyze HR and rhythm
• B. Assess for Homan’s sign
• C. Check BP
• D. Palpate the pedal pulses

Correct answer: A

Rationale: Before giving digoxin, the nurse will assess the HR and rhythm. The dosage will be held and the prescriber notified if the HR is below 60 bpm or if the cardiac rhythm has changes. Digoxin can cause bradycardia and electrical changes in the heart.

5. A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect?

• A. Appendicitis
• B. Bowel obstruction
• C. Urinary tract infection
• D. Kidney stones

Correct answer: D

Rationale: The ketogenic diet increases the risk of kidney stones.

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